A occassional contributor to The Concussion Blog, Matt Chaney, a journalist, editor, teacher and publisher, also has a blog. However, Chaney has published a book titled Spiral of Denial; Muscle Doping in American Football, so he is not new to finding and presenting good information.
Sideline concussed juveniles for three months, says breakthrough neuropath NP testing, lacks validation and might be harmful, critics charge NFL players rebuke ‘safer’ football through their ‘behavior modification’
By Matt Chaney
Posted Friday, January 28, 2011So-called concussion awareness is said to be sweeping American football, and Scott Fujita, veteran NFL linebacker, agrees to a point.
Yes, Fujita confirms, even hard dudes like him have sobered in their perspective. Head injuries are no longer considered trivial in football but as serious business, and NFL players get it, especially
Fujita, nearing 32 years old at arguably the game’s most violent position for Cleveland.In his mind the most menacing guys don’t appear so tough anymore, just more human, fragile—even as he targets one to smash on the field.
“I gotta be honest, I think about that every time I go in now to tackle somebody,” Fujita, 6-foot-5 and 250 pounds, said this week in a phone interview. “I’m concerned for my own safety as well as
theirs. I’m a married guy, I’ve got two young kids, and I see a lot more the big picture than I ever did before.”But has anything changed about danger in tackle football, the game that kills and maims? Is so-called safer play really taking over?
Fujita, member of the players union executive committee, doesn’t equivocate in answering, typical of his trademark frankness. “Do I feel safer with the emphasis on the rules and all that kind of stuff?
No, that doesn’t make me feel safer,” Fujita said. “Do I think the emphasis makes the game safer? No. Overall, I don’t, know.”
The entire article is VERY comprehensive and has some intriguing interviews, below are more excerpts;
Omalu —
Dr. Bennet I. Omalu, the pioneering sport-forensic pathologist who first linked brain damage to tackle football nine years ago, warns that players are dangerously mishandled still—despite official claims this season of “safer” play through rule changes and “concussion management” for the injured.
“That is the name of the game,” Omalu said of the rhetoric, calling it a “corruption at various levels” in information and science designed to deflect damning evidence amid crisis for football.
The official goal, Omalu charges, is not to protect life but to sustain football as pervasive in culture, sanctioned by American government, education, medicine, media and even religion, with elements of each profiting from the violent activity.
Omalu maintains that every concussed football player needs isolation from physical and mental stimulation followed by lengthy rest, further shielding—as he testified one year ago for the House Judiciary Committee. “Two weeks is insufficient time for the recovery of (cerebral) membrane and micro-skeletal injuries caused by concussions. The absence of symptoms does not mean that the brain has healed,” Omalu, chief medical examiner of San Joaquin County, Calif., told congressional members on Feb. 1, 2010.
“I recommend that if a child sustains a concussion in football, that child should be kept out of play for at least three months, or for the entire season to lower the risk of developing any degree of irreversible brain damage.”
Omalu’s public call went unheeded, but a rest mandate would’ve prevented at least one death of a teen player this season. In a recent phone interview, Omalu alleged that rampant, serious brain trauma continues to be disregarded at all levels of football, with injured players fast-tracked back to contact.
“What you do is remove the person from all types of stimulation,” Omalu stressed for diagnosed concussion, especially casualties of football. “You remove him (the athlete) from play. You remove him from school. You remove him from all types of intellectual stimulation.” Omalu is particularly alarmed about concussed juveniles, for the predominant attitude to quickly return kids to football, despite evidence suggesting young brains to be most vulnerable.
Efficacy of NP Testing —
Today’s general view that concussion management works or can work in tackle football is rendered highly suspect, if not effectively discredited, by independent review and mounting adverse opinion of experts and witnesses like players.
Linebacker Fujita notes he hasn’t been measured on neural baseline for two NFL seasons. Might not matter, anyway, for computerized NP testing has taken a systematic beating by reviewers of late. Observations and findings of medical literature from 2005 to 2010, listed without full author groups or first names, include:
- *Randolph et al, 2005, for Journal of Athletic Training
- *Patel et al, 2005, for Sports Medicine
- *Mayers, 2008, for Archives of Neurology
- *Duff, 2009, for ASHA Leader
- *Echemendia et al, 2009, for British Journal of Sports Medicine
- *Covassin et al, 2009, for Journal of Athletic Training
- *Maerlender et al, 2010, for The Clinical Neuropsychologist
- *Piland et al, 2010, for Journal of Athletic Training
- *Schatz, 2010, for American Journal of Sports Medicine
- *Comper et al, 2010, for Brain Injury
- *Eckner et al, 2010, for Current Sports Medicine Reports
Respected researcher and athletic trainer Kevin Guskiewicz stands firm in the Cantu camp, whose members today align with the NFL and football at-large, preaching that “concussion awareness” and “behavior modification” can save the game in largely present form, tens of thousand programs youth to adult.
“I think we’re headed in the right direction,” said Guskiewicz, PhD and chair of the Department of Exercise and Sport Science at the University of North Carolina. Last year he was appointed to concussion committees for the NFL, NFLPA and NCAA.
In recent past, colleagues Guskiewicz and Cantu criticized the NFL and union for foolishly challenging evidence linking the game to long-term cognitive impairment in retired players. But now Guskiewicz and Cantu are on-board with the NFL, avowing faith in new research, concussion management and rules enforcement while also receiving funding from “The League.”
The Cantu camp believes that lofty change and awareness for head injury can reform pro football and “trickle down” through the sport’s vast outback, thousands of cash-strapped colleges, schools and youth leagues.
But they affirm a daunting problem cited by critics: The education and adherence on part of millions of people, beginning with child athletes, for building the theoretical wall of concussion prevention and treatment within prevailing economic and political forces of inherently brutal football.
Guskiewicz is confident though. “We’ve come a long way in the last five years,” he said during a recent phone interview, speaking of protocols for diagnostic and return-to-play decisions. “We have validated neurocognitive testing, we have validated balance or postural stability testing,” he countered for doubters.
“I think the hardest part has been trying to convince the users (of tools), the clients, meaning all the high schools out there, colleges, even the pro teams,” Guskiewicz continued. “I mean, at NFL level, they’ve only over the last two years mandated (ImPACT or like NP) testing for all their football players. And they’ve put into place and standardized, to some extent, return-to-play protocols and having independent neurologists be part of the evaluation process.”
Fujita II —
In fact, Fujita says he’s only been NP-tested a few times during nine years in the NFL. Despite all the talk by management and associate experts, swearing newfound vigilance and concern over brain health in players, Fujita hasn’t seen tangible effect.
His neurological baseline wasn’t re-assessed this season, as concussions exploded into the biggest controversy for American football in more than a century. Fujita even played on the infamous October Sunday at Pittsburgh, Browns versus Steelers, when three shocking headshots leveled guys within minutes.
Had Fujita suffered a concussion this season—or been diagnosed—the NFL would’ve been without proper neural data to gauge his condition. “I took one (a baseline) probably, maybe three years ago?” he said, considering. “Maybe two years ago was the last time, down in New Orleans.”
“Yeah, I think it’s been at least two years,” the linebacker determined. “And there have been a whole lot of train wrecks in two years.”
Epidemic —
“I’m not saying that doctors or researchers are acting unethically. But this is an area where such conflicts could potentially arise, and so vigilance is required, as well as attention to issues of research and medical ethics.”
Epidemiologist Charles E. Yesalis works outside concussion management in football, but the independent scientist sees analogy in his expertise of drug use by athletes, specifically the in-house setup of research for ineffective anti-doping—or “prevention” testing in that issue. “That’s something that’s really kept me in the drug research, because the politics are so interesting, to see how (the issue) plays out in the cultural aspects and so forth,” Yesalis said in a phone interview.
And head injury is bigger than doping, Yesalis says, with higher stakes for tackle football because smoking-gun evidence links long-term problems of former players. In response, the NFL and all of football must claim remedy is possible—or concede nothing can be done.
“The intricate part of the culture of the game, violence, isn’t going away anytime soon,” Yesalis said. “It’s very obvious why the NFL is concerned about this. I think that’s why they’re dumping money on this, and this academic show. … This is going to eclipse the drug problem, and it probably already has.”
Like anti-doping in sport, invalid and woefully funded, Yesalis believes some experts are in too-deep with American football, ethically and legally, for their promising to police head injury with tools lacking proper vetting. Funding is paltry, regardless of a few million thrown around by billion-dollar profiteers.
Neuropsychological tests both written and computerized are good in theory but far from proven for sound specificity and sensitivity, only possible through peer review and replication in the realm of long-term, random clinical trial.
Omalu II —
Narrowing to medical analysis, making a base comparison easy for Football America, Omalu discusses and teaches the volatility of head trauma capable of combusting upon further pounding into lasting damage.
“The brain is a post-mitotic organ. It means the brain cells do not have the ability to divide and create new cells. … A very good example I always give people: When you suffer a stroke, your stroke cannot be cured (at cellular level). Once you’ve suffered a stroke, it is permanent. Even if you die 50 years later and we examine your brain, we see the stroke. It creates a space in your brain.”
“Same applies to concussions. A concussion is simply fracture. You know how you break your bone? That is what a concussion is, but now it is on the cellular level. A concussion is a fracture of the skeleton of the brain cells. If you fracture your bone, the NFL will keep you out of play for the entire season. They say it is a season-ending injury. But the bone has the ability to divide, and create new bone, and heal. A fracture can become healed, OK?”
“But—a fracture of the brain, which is a concussion, does not have the ability to heal as well as the bone. The bone is more resilient, but somebody fractures his bone you keep him out of play for three months. But if somebody fractures his brain? You keep him out of play for only two weeks? Does that make sense even if you’re not a doctor?”
Does for Dr. Cantu in many cases. He says he’s secure in knowing most concussed players return to football rapidly, and he does not endorse mandated lengthy rest in every case regardless of severity. “We don’t have the evidence to say that should be the case for all players, no. Those who clear very, very quickly—symptoms are over in less than an hour, or less than a day—I think can safely go back a week after they’re asymptomatic.”
“But it’s true: There are a lot of questions still to answer,” Cantu added. “There are real issues with regard to taking on this trauma quite young in life. But I don’t think we quite know enough about what the risks are.”
Needless to say this is a good article to read and reflect on. Work like this needs to be highlighted and not kept from public consumption. Knowing about the issues, both good and bad, is what is needed to resolve issues and “norm” the situation and move into better performance.
The Concussion Blog 
This article raises many imperative questions that I feel were due to be addressed, and are that of which I never would have considered to raise doubt or make connections to with regards to neuropsychological testing. Return-to-play guidelines have not met a true consensus all throughout up till this date, and are infected with speculations that rightfully question the integrity of what we see in the medical community today. Why is it that there is no common ground for concussion management? The general answer assumption had always been, wait till the symptoms resolve, but when do we truly ever know that? In my opinion, neuropsychological testing such as ImPACT are useful for the diagnostic process, but really should not be given too much power in the overall evaluation. What needs to be further investigated is this diffusion tensor imaging, the utilization of the fMRI, for it could hold the key to what may possibly be a revolutionary technique in management. The issue in this will always fall back on money, however. Money. Money in the NFL, money for college football programs, money for ImPACT testing, money for legislative requests, money for neuroimaging techniques. We must maintain that this seemingly endless path of concussive-limbo has a future potential to unveil the TRUTH behind mild traumatic brain injuries. Football will always be dangerous, and players understand the risks that come with the game. There are ways to theoretically limit the prevalence of concussion, but at what risk does such measures threaten the foundation of the game? This cycle we find ourselves in, wondering where to go and how to go about it, requires the collaboration of unbiased, dedicated, and deterministic personality to take on football’s concussion crisis. Something must be done, questions MUST be answered… for the sake of football, and for the sake of our children’s futures.
This is why John is on board! Very articulate and concise.
Excellent post, this (Chaney’s blog post) is one of the best articles on TBI I’ve ever read. Thanks for posting it here.
I still stay steadfast to the belief that MUCH, MUCH more information is needed to grasp a clear picture on this entire issue. I/we use ImPACT, and I am not ashamed to admit it, however we are careful to use it as I believe it is intended for, a tool. Over and over I have said this, Chaney brings many articles and others in the field that question the reliability of this test as a serial diagnostic. I have and will continue to run posts about NP test on the market, mainly for the consumption of those reading. Education is the key, learning about what we don’t know will lead us to the truth.
The silence is sometimes deafening when you ask questions, however Chaney did a good job of “nailing” down some issues, at the very least for further examination. It is going to take a collective approach to tackle (pun intended) the ever expanding realm of concussions. The more transparent the issue is with policy makers the better grasp we will have. This is not the 60’s, 70′ or even the 00’s, people have access to more and more information. Perhaps an info overload for some, but educating and bringing as much unbiased info to the forefront will make things much more tolerable.
Again, the injury called concussion is bound to happen, that is not the issue that many seem to be struggling with, rather the opportunity to make a name or money off the management of the injury. As of now there is no golden bullet, what is a common theme amongst EVERYONE is that being asymptomatic is the key to recovery and no prolonged effects. This is a start, because just 2-3 years ago we were not even this far.
I thank Matt for his contribution and hard work, and would invite anyone and everyone to comment on this.
What I found interesting is that none of this would be possible without athletic trainers. Notice how many research articles on concussions were referenced from the Journal of Athletic Training. Notice what medical profession works with the most concussions – athletic trainers. Notice what medical profession is still clamoring for more research, more knowledge, more skill, more tests; it is the athletic trainer! We are on the front lines of this battle. We are the ones who work with the young athletes on a daily basis before, during and after a concussion. We are the ones who are referring kids to the doctors and we are the ones who tell the coach and parents that the concussed athlete can’t play and are there to make sure they don’t!
America’s high school athletes need athletic trainers!
Boooom!!! This is VERY TRUE… No other health care profession has the ability to monitor the injured adolescent on a daily basis (if the school has daily coverage). Daily is far greater than 1 week or 1 month follow ups.
I’ve read the article and I find it very interesting. I’ll comment on things that stood out to me right away and later I’ll develop a more comprehensive response.
My first thought is there’s no way a “3 month minimum layoff” is going to work. In fact, I believe it’s a step backwards. If an athlete knows that s/he is going to face 3 months out of their sport, they are going to hide the symptoms even more. If you’ve worked with athletes at all, you understand how athletes try to hide things now. I agree with Dr. Guskiewicz with regards to this time period. It appears this minimum time has come out of nowhere. That won’t work because there is no evidence to prove it’s the “right” time. What happens when a kid suffers a concussion, is asymptomatic for 3 months, cleared to return, and then suffers another concussion and dies? Are they then going to tell us that all kids should sit for 6 months?
“A client pays $500 to $700 annually and training of novice personnel costs extra, for small workshops held in Pttsburgh.”
Who are these “novice personnel” that are mentioned?
Keating has reported on all of this, “conflict of interest” The Nfl/NHL is not doing enough, a mandate of a medically fit oral appliance is needed, no doubt. Cantu stated in congressional testimony, the chin and jaw are a factor in concussion, infact “Pugilistica Dementia or CTE manifests as dead brain cells just milimeters from the jaws contact point on the skull base. The medial temporal lobe, exactly where the temporal mandibualr joint is, the Pentagon and Army are moving forward with research. Yet no meaningfull initiative is being proposed by the NFL, only tooth related mouth guard research as far as I know. The condition known as a boxers Glass Jaw, is accepted to make boxers more prone to mtbi and will not and cannot heal itself, only a jaw correcting appliance can help. Sending a player like Savard out on the ice without some sort of jaw protection is insane given the chin shot he took from Cooke. Just as Crosby is now on that same path, he should be fitted with a corrective mouth guard. When Bergeron was hurt the second time Mick Colageo reported he was fit by the Patriots dentist. You really have to look at what Bergeron is doing to stay healthy. This week, the big story is Arron Rogers and the Peppers hit to the chin. He, like many NFL players, does not wear any mouth protection, the chin is an area helmets just can’t protect. A hit to the Rogers jaw early, will change the game, just like the chin blow Sanchez took from Banta Cain, when the Patriots beat the jets 43-3. These mtbi are a game changer, the need for further investigation of this element of concussion should supercede any aftercare initiatives.
Thanks for this great post. This is critical to consider.
I think we also need to consider very carefully the impact that sitting out will have on the athletes themselves. If you are the kind of person who bases much of their identity on athleticism and involvement in team sports (as I did when I was a student athlete), and you don’t have a replacement for this kind of activity that gives you a sense of who you are, as well as self-worth, sitting out can have huge personal consequences. I think that losing that connection with yourself and your team plays a big part in suicides by concussed student athletes. Being sat out can be a devastating blow, when your sense of self is still being formed, and you have nothing to replace it with. Not wanting to be benched caused me to make light of my concussions, and it sent me back into play, when I got hurt again. Not good. But there was no way I was going to be sidelined over a little bump on the head.
Unless we find a way to provide that same level of intensity and connectedness to student athletes after they are injured, we continue to run the risk of them hiding their symptoms and avoiding treatment and returning to play too soon. We need to enlarge the worlds of student athletes to include other activities that give them the same level of belonging and satisfaction.
The same can probably be said for professional athletes. When your athleticism is “all you have” — not being good at academics and feeling socially impaired, as we “jocks” often are/do — and that’s taken away, it’s a blow that is hard to overcome. Add on top of that the impaired cognitive faculties, and you’ve got yourself a time-bomb of sorts.
Sitting athletes out is only part of the solution, and if it’s not fully expanded, there’s only so much we’ll be able to do to protect these athletes from further injury. Nobody in their right mind, who loves to play, who LIVES to play, is going to volunteer information that could lead to being benched. It’s not in our nature. It IS in our nature to suck it up and get back out there and try even harder the next time.
We need to make it okay to heal, we need to make it okay to protect ourselves from serious injury. And we need to show that there are other options in life that have as much promise and offer as much teamwork and sense of purpose as the collision sports that sidelined the concussed athlete.
Until that time, we have the serious problem of athletes hiding or downplaying their injuries and running the risk of even more — and worse — injuries down the line.
Thanks again for this important post.
BB
BrokenBrilliant, thanks! That is an excellent post. You have a great point about the psychological aspects of it. 3 months of “shut down” for someone that lives and breathes sports could really be detrimental. I worked some summer camps last year and saw a few concussions. One day a 12 year old kid came in after apparently bouncing his head off the floor. He walked into the athletic training room and kept commenting about how bright it was. The lights in the ATR were pretty dim, but over and over again he would talk about the light. After finishing my eval, I started talking to him about what a concussion was, etc. I told him he wasn’t going to be able to play the rest of camp (another day). He started crying. He told me how much his team needed him. And on and on. This is a kid who may never play the sport past junior high for all we know! Just think if it’s a high level high school or college athlete who had dedicated his/her life to the sport!
And this doesn’t just apply to an athlete. Concussions/head injuries can occur to kids and adults not involved in athletics. When a brain injury occurs at any age, it can affect one’s self-identity, especially as social support can dramatically and significantly disappear at the time one needs the support most.
I would like to see studies begin about the impact of technologies bein used in the school for instruction,, such as the SmartBoard, on the healing brain after a TBI. I think this can continue to cause trauma, much as the information that Dr. Omalu has described about how the neuropsychological and IMPact testing during the acute phase can continue to cause damage. While much rapid advancement of awareness is occurring, I still think there is ignorance and denial in the educational system and information is needed there, where there are not athletic trainers necessarily, but teachers who have daily interactions. The data collected for a brain injured student, can help further studies, whether or not the individual was involved with sports or not (and do keep in mind that many who used to be student athletes may not be able to continue in this role). It is very frustrating to bring data to the school administration about how a brain injury can impact learning or how learning can impact the brain injury recovery that will be ignored because “that applies to athletes,” and a student may have similar or the same symptoms and difficulties, but the information is not considered relevant for a non-athlete. Brain injuries do not occur only in the context of sports and while that might make it easier to identify a group of appropriate subjects, I hope it will be expanded, as we need to value our youth and help all of them prepare to be productive members of society, regardless of how the brain injury originally occurred.
So much emphasis needs to continue on changing the culture surrounding those with mental health impairment.
BB and Hopp… Great commentary… Below is what I wrote in response to Chaney my thoughts after digesting the information and doing some more research… Let me preface this by saying the work that he did was AMAZING and this could even be considered a “sentinel moment” as we reflect where we are…
I am a little leery of the extended/mandatory 3 months… By slapping that on the injury, I FIRMLY believe that more and more athletes will not report the injury to begin with. Leading us right to where we were a few years ago. We are seeing this in the sport of rugby where their sanctioning body has a mandatory 3 week recovery period for concussion, the reporting of concussions in that sport are dangerously low.
It is paramount that those that deal with the injury use every tool they have and are trained with to make the proper decision. Having research in the open, by that of Omalu and others is part of the process. Any health care professional worth their salt will take this information in consideration when dealing with injuries.”
This includes knowing the athlete and very few people will have this ability; parents, coaches, teachers at the adolescent level and peers and family at the pro level. There is one health care profession that has this ability as well, athletic trainers, but only if they are at the school on a daily basis. This allows the athletic trainer to be a “student” of the behaviors of the individual and to communicate with those that can monitor their grades, a very good indicator of brain health, in my experience. The athletic trainer, although not a MD or Neuropsych, will see the injured student more often than the 1 week or 1 month follow ups of the docs.
An example of this would be a case that I had 2 years ago, a player was diagnosed with a concussion, we were early in the ImPACT phase at the school and he had been cleared by his physician, we used the NP tool and found that his scores were “back to baseline” all things that would lead most to believe that he was ready to return. However I felt something was just not right with the kid. His usual disposition of being an outgoing “class clown” funny nature was not present. Rather he had become very serious and subdued, almost an intravert add to that when quizzing his mother and teachers I found out that his concentration level was not up to par and that they felt he was “off”. They had observed the same issues. He was not allowed to return to play and after discussing with the family and the kid they agreed. Fast forward 18 months later and the kid that was concussed came back from college to tell me that he “finally felt” himself. Each injury will present and resolve in different manners, like an ACL surgery (some can get back in 3 months and some take a year), but as Omalu says a “fracture of the brain” is much more serious.
It is imperative that the message be sent and received by everyone and the stigma is erased, but even more urgent is the fact that athletic trainers need to be at schools on a daily basis as a trained health care provider that is educated in concussions that can make informed decisions using all information they have at their hands.
Great point about trainers being able to spot issues. It is a tricky situation, isn’t it, where everybody has a different piece of the puzzle, and there are varying levels of motivation to report what’s really going on.
I recently saw an article/report about a high school football player who was concussed and got sidelined. Rather than go back to football, he started training to become an auto mechanic, which seems like an ideal choice to me — provided the person in question wants to be an auto mechanic, of course. Having structure and something to work towards, which is actually giving you a leg up in your future, can be a great way to offset the loss of playing time, comraderie from the team, and the structure of practices and games.
It’s critical that proper care be taken and attention be given. And I think it’s also important to consider the well-being of the athlete in question, so they don’t end up feeling like their life is over when they can’t play.
This is a tough subject. I’m glad folks are talking about it as much as they are.
Thanks for your work on this. It truly is inspirational – and much needed.